BALTIMORE — While veterans and servicemembers who have experienced a single unprovoked seizure and the clinicians who treat them would like clear, consistent next steps, new guidelines take them into solidly gray areas.

“Some physicians treat everyone with first seizure; some don’t treat anyone. The new guidelines do not give a black-and-white answer. They say treatment and management really needs to be individualized,” said Allan Krumholz, MD, director of the Maryland Veterans Affairs Epilepsy Center of Excellence and professor of neurology at the University of Maryland School of Medicine in Baltimore.

Krumholz was the lead author of guidelines published this fall by the American Academy of Neurology (AAN) and the American Epilepsy Society (AES). The report in Neurology was the fourth in a series on managing epilepsy in children and adults.1

The professional organizations recommend weighing the risk of another seizure and how a subsequent seizure might affect the patient’s life against tolerance of side effects, patient preferences and risk of antiepileptic medications to develop the best strategy for the individual.

Patient education and joint decision-making are key to the approach. “It’s very different from the usual paternalistic or maternalistic attitude toward treatment,” Krumholz told U.S. Medicine.

Education includes clearly conveying the risk of a second seizure, which is highest in the two years following an initial unprovoked seizure. During this period, the risk ranges from 21% to 45%. Medications can cut that rate in half, according to Krumholz.

Predicting who is most likely to experience another seizure is not quite a shot in the dark, however. Four factors double a patient’s risk:

a prior brain insult, such as a concussion that caused the seizure,

an EEG that shows spikes or epileptiform abnormalities,

a significant brain-imaging abnormality such as a lesion, or

a first seizure during sleep.

The recommendations note that “caution is urged regarding the calculation of additive risk of seizure recurrence after a first unprovoked seizure,” as the interaction of the various risk factors remains unknown.

How or why all four increase risk also remains unclear. “The first three factors have a logical foundation,” Krumholz explained. “We don’t know why nocturnal seizures are associated with increased risk, but we saw a correlation in two studies.”